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Your Details

Note: Questions marked by * are mandatory

*This is a mandatory field. Title

*This is a mandatory field. First Name

Middle Name(s)

*This is a mandatory field. Surname

*This is a mandatory field. Date of Birth

*This is a mandatory field. First Line of Address

Second Line of Address

*This is a mandatory field. Town/City

*This is a mandatory field. County

Herefordshire
Worcestershire

*This is a mandatory field. Postcode

*This is a mandatory field. Email Address

*This is a mandatory field. Please confirm your email address

*This is a mandatory field. Contact telephone number

Mobile number (if different from above)

*This is a mandatory field. Preferred method of contact:

Email
Phone
Text/SMS
Post

*This is a mandatory field. Preferred time of contact:

Morning (9am - 1pm)
Afternoon (1pm - 5pm)
Anytime (9am - 5pm)

*This is a mandatory field. Name:

*This is a mandatory field. Date:

	Yes	No
*This is a mandatory field. Data protection: I agree that the information I have provided will be used to help achieve my aims and goals whilst enrolled at the Wellbeing and Recovery College. All records treated in strict confidence, kept in a secure environment and only accessed by appropriate staff. We do not share this information with any other individuals or organisations involved in the Wellbeing and Recovery College. You may request any information that we hold on you at any time.
*This is a mandatory field. We would like to contact you twelve weeks after the last course you attended to find out how our courses/workshops have contributed to your recovery journey. Please tick the box if you are happy for us to contact you in due course.

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